Abstract

Objective A comprehensive systematic review of economic evaluations of complementary and integrative medicine (CIM) to establish the
value of these therapies to health reform efforts.

Data sources PubMed, CINAHL, AMED, PsychInfo, Web of Science and EMBASE were searched from inception through 2010. In addition, bibliographies
of found articles and reviews were searched, and key researchers were contacted.

Eligibility criteria for selecting studies Studies of CIM were identified using criteria based on those of the Cochrane complementary and alternative medicine group.
All studies of CIM reporting economic outcomes were included.

Study appraisal methods All recent (and likely most cost-relevant) full economic evaluations published 2001–2010 were subjected to several measures
of quality. Detailed results of higher-quality studies are reported.

Results A total of 338 economic evaluations of CIM were identified, of which 204, covering a wide variety of CIM for different populations,
were published 2001–2010. A total of 114 of these were full economic evaluations. And 90% of these articles covered studies
of single CIM therapies and only one compared usual care to usual care plus access to multiple licensed CIM practitioners.
Of the recent full evaluations, 31 (27%) met five study-quality criteria, and 22 of these also met the minimum criterion for
study transferability (‘generalisability’). Of the 56 comparisons made in the higher-quality studies, 16 (29%) show a health
improvement with cost savings for the CIM therapy versus usual care. Study quality of the cost-utility analyses (CUAs) of
CIM was generally comparable to that seen in CUAs across all medicine according to several measures, and the quality of the
cost-saving studies was slightly, but not significantly, lower than those showing cost increases (85% vs 88%, p=0.460).

Conclusions This comprehensive review identified many CIM economic evaluations missed by previous reviews and emerging evidence of cost-effectiveness
and possible cost savings in at least a few clinical populations. Recommendations are made for future studies.

Key messages

The cost-utility analyses found were of similar or better quality to those published across all medicine.

The higher-quality studies indicate potential cost-effectiveness, and even cost savings across a number of CIM therapies and
populations.

Strengths and limitations of this study

The strengths of this study are the comprehensive search strategy, the use of two reviewers, the use of multiple measures
of study quality and the identification of higher-quality studies, for which results are reported in detail, via an objective
short-list of quality criteria, which reduced the potential for bias.

The weaknesses of this study are similar to those of the other systematic reviews: reviewers were not blinded to journals
and article authors, and some aspects of what makes a quality economic evaluation could not be judged from what was reported.

Publication bias was not assessed. However, it is not clear as to whether publication bias is relevant, given the purposes
of this review.

Introduction

Between 1990 and 2007, four nationally representative surveys demonstrated that a third or more of US adults routinely used
complementary and alternative medicine (CAM) therapies to treat their principal medical conditions.1–4 Total expenditures for CAM therapies were estimated at US$14 billion in 1990,1 US$27 billion in 19972 and US$34 billion in 2007.4 The 2007 US National Health Inventory Survey found that out-of-pocket expenditures for CAM therapies accounted for 11% of
all out-of-pocket healthcare expenditures by Americans.4 Similar use numbers are seen in other countries.5–8 However, despite the popularity of and substantial expenditures on CAM therapies, their cost-effectiveness remains ill-defined
and controversial.

Economic evaluations allow costs to be included, alongside data on safety and effectiveness, in healthcare policy decisions.
As healthcare costs rise, the availability of these economic evaluations becomes increasingly important to the formulation
of disease management strategies which are both clinically effective and financially responsible. According to the National
Center for Complementary and Alternative Medicine (NCCAM), CAM is ‘a group of diverse medical and healthcare systems, practices
and products that are not generally considered part of conventional medicine’.9 In not being part of conventional medicine, individual complementary therapies and emerging models of integrative medicine
(ie, coordinated access to both conventional and complementary care)—collectively termed as complementary and integrative
medicine (CIM)—are often excluded in financial mechanisms commonly available for conventional medicine,2 and are rarely included in the range of options considered in the formation of healthcare policy. The availability of economic
data could improve the consideration and appropriate inclusion of CIM in strategies to lower overall healthcare costs. In
addition, economic outcomes are relevant to the licensure and scope of practice of practitioners, industry investment decisions
(eg, the business case for integrative medicine), consumers and future research efforts (ie, through identifying decision-critical
parameters for additional research10).

A number of systematic reviews of economic evaluations of CIM have been published.11–23 Five of these prior reviews attempted to capture all economic evaluations of CIM therapies across all conditions.11,19–21,23 However, it is unclear as to whether all or even the majority of economic evaluations of CIM have been identified by these
reviews. The searches are dated; the search strategy in the most recent review only captured articles published through 2007.23 The databases searched were limited—for example, only one used CINAHL,21 and only two others used EMBASE,19,23 in addition to Medline and AMED. Finally, these reviews generally used limited search terms to identify CIM studies. All
but one only used variations on the terms ‘complementary’ or ‘alternative’ ‘medicine’ or ‘therapy’. Unfortunately, other reviewers
have found that these search terms do not capture all CIM studies,24,25 which may be a reflection of the difficulty in defining what is and is not CIM.26 The search by Maxion-Bergemann et al11 also added individual therapies as search terms, but only included homeopathy, phytotherapy, traditional Chinese medicine,
anthroposophic medicine and neural therapy. No search included ‘integrative medicine’.

The goal of this paper is to identify, to the extent possible, all published economic evaluations of CIM, describe the types
of CIM evaluated and the clinical conditions for which they have been evaluated, and identify the recent (and therefore, most
cost-relevant) higher-quality studies and highlight their results for policy makers. We also make recommendations for future
economic evaluations of CIM.

Methods

Six electronic databases were searched from their inception through December 2010: PubMed, CINAHL, AMED, PsychInfo, Web of
Science and EMBASE. To be as comprehensive as possible, a combination of 11 medical subject headings (MeSH) and 39 other search
terms were used (box 1). In addition, bibliographies of found articles and reviews were searched, and key researchers in various areas of CIM were
contacted for their lists of known studies. Although non-English language articles were collected, they are not analysed in
this review.

Defining a comprehensive search strategy for CIM is challenging.24,27–29 There have been a number of efforts to develop a concise definition of CAM.26,30 This review used the one developed by the members of the Cochrane CAM Field31 and then added the terms ‘integrative’, ‘integrated’ and ‘collaborative’ medicine. The Cochrane CAM definition starts with
the NCCAM definition9 and then refines it by specifically including all therapies ‘based upon the theories of a medical system outside the Western
allopathic medical model’ (eg, traditional Chinese medicine and Reiki), and including others depending on the context and
setting of their use. The context of use considers treatment/condition combinations and excludes those ‘currently considered
to be standard treatment’, and the setting of use generally includes self-care and therapies delivered by CIM providers, but
excludes therapies ‘delivered exclusively by conventionally credentialed medical personnel or exclusively within hospital
settings’. Therefore, therapies such as chemotherapy regimens (eg, chronotherapy32), and therapies requiring surgical implantation (eg, neuroreflexotherapy33) or the placement of a feeding tube34 were not included even though these therapies appeared in our search. In cases where CIM therapies (eg, biofeedback or hypnosis)
were included as part of a package of care (eg, with cognitive behavioural therapy), a judgement was made as to whether the
CIM portion of the treatment made up half or more of the overall package of care under study. If so, the package of care was
included as CIM. Because more than half of CIM users use multiple CIM therapies,35 studies of packages of therapies and coordinated care were identified as such.

Articles were categorised as full economic evaluations if they compared the costs (inputs) and consequences (economic, clinical
and/or humanistic outcomes36) of two or more therapeutic alternatives applied to the same patient population (ref.37, p. 11). Otherwise, they were considered partial evaluations, for example, cost-identification or cost-comparison studies.38 Studies that estimated resource utilisation were included as economic evaluations if the utilisation data were detailed enough
to allow monetary valuation.

Two reviewers (PMH and BLP) evaluated all articles for inclusion and extracted all data. Disagreements were resolved by discussion
between the two review authors, or, if needed, by the other coauthors. Because the results of economic evaluations can rapidly
lose relevance with time, mainly due to changes in practice patterns and cost structures, data were extracted only from the
economic evaluations published 2001–2010. Extracted data were entered into an Excel template developed for a previous review.20 The type(s) of CIM evaluated and the target population were captured for all economic evaluations. Various indicators of
study quality were captured for all full economic evaluations, and more detailed data and results were captured only for those
full economic evaluations that met five quality criteria.

The quality of an economic evaluation can be judged along two general dimensions: (1) whether the study was a quality measure
of outcomes for its target population and location—that is, whether it was internally valid; and (2) whether enough information
is provided for the study's results to be transferable (‘generalisable’).39 Health outcomes are to some extent considered generalisable across settings; however, because resource availability, practice
patterns and relative prices can vary greatly, economic outcomes usually are not.40 Therefore, one goal in economic evaluation is to ensure the transferability of study results—that is, to provide enough study detail so that results can be adapted (usually via modelling) to apply
to other settings.39 The 35-item BMJ checklist captures components of both dimensions of quality and was applied to all full economic evaluations.41 We also chose five quality criteria by which to identify a subset of full economic evaluations to highlight as being of most
interest to policy makers. These quality criteria are based on recommendations made by the US Panel on Cost Effectiveness
in Health and Medicine 42 and by well-known experts in the field,37 and focus on the quality of the underlying study (the first type of quality):

Because cost-effectiveness analysis (CEA) is comparative, to ensure that results are useful to decision makers, one of the
alternatives to which the CIM intervention was compared must be some version of commonly available (routine, standard or usual)
care.

The analysis must explicitly or implicitly use (and include all relevant costs from) at least one recognised perspective—for
example, society, third-party payer, hospital or employer.

Since ‘an economic evaluation of a healthcare programme is only as good as the effectiveness data it is built upon’ (ref.43, p. 232), health outcomes must be from randomised controlled trials or non-randomised controlled trials using either statistical
adjustment or matching to address baseline differences.

Since having patient-specific data on both costs and outcomes is an advantage for internal validity,44 resource use must be a measured outcome of the study. Modelling studies utilise the results of other published studies, therefore,
are exempt from this criterion.

Because uncertainty in an economic evaluation comes not just from sample variation, but also from assumptions made,45 a sensitivity analysis is required.

Because the prices used to value resources are highly location-specific and setting-specific,39,46 we also note, for the articles meeting the above criteria, the presence of a study reporting criterion essential for the
transferability of study results (usually via modelling):39,40 separate reporting of unit costs from resource use for economic evaluations alongside trials, or from model parameters (eg,
transition probabilities) for economic evaluations using models.

Other data extracted for the economic evaluations which meet the five study-quality criteria are: treatment and study duration,
primary clinical and economic outcome measures, the setting in which treatment took place, study design and sample size, the
type (table 1) and perspective (ie, the point of view used to define costs) of the economic analysis, and incremental cost-effectiveness
of the CIM alternative compared to usual care. Incremental cost-effectiveness is reported in 2011 US$ and is calculated from
reported results by first converting the study currency to US$ using the Federal Reserve annual exchange rate47 for the study's currency year and then inflated to 2011 values using the medical care component of the Consumer Price Index.48

Finally, up to three additional quality measures are included for each of these studies. The Tufts CEA Registry49 quality score is recorded when it was available (note it is only available for cost-utility analyses, CUAs). A Jadad score50 with minor modifications (the two possible points for blinding were replaced with one point for the use of a blinded assessor)51 was calculated for the economic evaluations that included a randomised trial. The percentage of the applicable items from
the 35-item BMJ checklist that were met by each article is also reported.41

Results

As shown in figure 1, the database search identified 270 published economic evaluations. An additional 68 articles were added through the bibliography
and expert-supplied list search for a total of 338 economic evaluations of CIM. Of these, 204 (60%) were published from 2001
through 2010 (114 full and 90 partial economic evaluations). Of the recent full economic evaluations almost all (103, 90%)
examined the effect of one CIM therapy and most of the balance (10, 9%) examined the effect of two or more CIM therapies provided
by the same practitioner. Only one looked at the effect of multiple CIM therapies provided by different CIM providers.52 CIM was generally evaluated as an adjunct to usual care.

As shown in table 2, the 204 economic evaluations published in the past 10 years are spread across a wide range of CIM therapies applied to a
number of different study populations. The biggest concentration of full economic evaluations (19 in number) pertained to
the use of NCCAM's definition of manipulative and body-based practices (eg, chiropractic, osteopathic manipulation, massage,
etc) for the treatment of back pain.53–72 However, even this subgroup is fairly heterogeneous in terms of the therapy (or therapies) tested and/or the type of back
pain treated. Eight of these comparisons involved chiropractic care for back pain; one for chronic,53 one for acute57and six for either type.59,60,63,64,67,68 Five evaluated spinal manipulation and manual therapy provided by physiotherapists for chronic back pain (one),65 acute back pain (two)58,69 or either (two).56,68 Four involved osteopathic manipulation; one for chronic71 and one for subacute back pain72 and two for musculoskeletal conditions including back pain.66,68 Three evaluated massage; two for chronic55,62 and one for acute back pain.57 The last two studies evaluated a musculoskeletal physician (treatment ‘with a combination of manual therapy, injections,
acupuncture and other pain management techniques’) for orthopaedic referrals;54 and a Finnish folk medicine practice called ‘bone setting’ for the treatment of patients with chronic back pain.61

Table 3 shows the results of the application of the 35-item BMJ checklist to the full economic evaluations published 2001–2010.41 On average, the number of applicable items met by each article stayed fairly constant during this period. However, the application
of two key items (ie, the proper use of discounting and the inclusion of sensitivity analysis) and the disclosure of funding
sources improved significantly, and reporting of the study time horizon worsened significantly. As expected, the average overall
and individual-item percentages were higher for the higher-quality articles (those meeting the five study-quality criteria)
and for CUAs of CIM. It is not surprising that CUA's quality is higher. They generally involve more effort than other CEAs
and are required or recommended by various national guidelines.42,73–75 Nevertheless, it seems as though the quality of CUAs of CIM is generally comparable to, or slightly better than, that seen
in CUAs across all medicine, at least in terms of the Tufts quality score, disclosure of funding sources and the five items
where comparable data are available.76,77

Types of individual complementary and integrative medicine (CIM) therapies studied for various conditions and in various populations:
2001–2010 (reported as the ratio of the total number of economic evaluations to the number of full economic evaluations)

The number of full evaluations meeting each of the five study-quality criteria are: comparison to usual care 97 (85%), all
costs from a recognised perspective 96 (84%), health outcomes from a randomised or matched-control trial 86 (75%), patient-specific
data on costs and outcomes 105 (92%) and sensitivity analyses 37 (32%). Sixty-two (54%) of full evaluations met the first
four of these and 31 (27%) met all five. A summary of the results of these 31 higher-quality articles (covering 28 different
studies) is shown in table 4.54,60,62,68,71,78–103 Twenty-two of these articles (19 of the studies) reported resource use (trials) or model parameters (models) separate from
unit prices—a minimum measure of study transferability.54,62,68,71,78,80–8587–93,95,100,101,103 For those studies which included a randomised trial, the modified Jadad scores ranged from 2 to 4 on a scale from 0 to 4.
The Tufts CEA Registry quality scores for the studies containing a CUA ranged from 4 to 6.5 on a scale from 1 to 7. The percentage
of the applicable items on the BMJ checklist met by these studies ranged from 66% to 97%.

Of the 56 comparisons made in these studies, 16 (29%) are cost saving—that is, the added CIM therapy had better health outcomes
and lower costs than usual care alone. Cost savings were seen for acupuncture alone (instructional visits with an acupuncturist
followed by home self-care by the partner for pregnant women with breech presentations at 33 weeks in terms of reductions
in both breech presentation at birth and ceasareans in the Netherlands,91 and treatment by traditional Chinese medicine-trained licensed acupuncturists in private acupuncture clinics in the UK for
low-back pain in terms of quality-adjusted life-years or QALYs from the societal perspective85) and in combination with other therapies (along with manual therapy, injections and other pain management for patients referred
to an orthopaedic surgeon's office in Scotland who were unlikely to need surgery in terms of both improvements in health-related
quality of life and QALYs54). Cost savings were also seen for manual therapy delivered by a physiotherapist, who is also a registered manual therapist,
for neck pain in terms of perceived recovery, pain, neck disability and QALYs82; for preoperative oral supplementation with arginine and ω-3 fatty acids for patients with gastrointestinal cancer undergoing
surgery102; for vitamin K1 supplementation for postmenopausal women with osteopenia and osteoporosis in terms of QALYs103; for supplementation with vitamins C and E and β-carotene for cataract prevention90; for fish oil supplementation in men with a history of heart attack87; for tai chi to prevent hip fractures in nursing home residents95 and for naturopathic care offered through a worksite clinic for chronic low-back pain in terms of both reductions in absenteeism
and gains in QALYs.80

Of the 28 cost-utility comparisons, one (massage for low-back pain62) was dominated— that is, had worse health outcomes and higher costs than usual care. Five (18%) are cost saving,54,80,82,85,103 5 (18%) have incremental cost-effectiveness ratios (ICERs) between US$0 and US$10 000 per quality-adjusted life-year (QALY),68,71,81,85,97 and 89% had ICERs less than US$50 000/QALY, a threshold often considered to represent the upper limit of society's value
for a QALY.104 The cost-saving cost-utility studies were included in the paragraph above (ie, those that mention QALYs). The studies with
cost-utility ICERs between US$0 and US$10 000 per QALY were: treatment by traditional Chinese medicine-trained licensed acupuncturists
in private acupuncture clinics in the UK for low-back pain.85 hospital-based acupuncture by licensed oriental medical doctors in South Korea for 60-year-old women with first-time acute
low-back pain,81 acupuncture from physicians with at least 140 h of training (A-diploma) in Germany for patients with dysmenorrhoea,97 osteopathic spinal manipulation by a general practitioner who is a registered osteopath in the UK for patients with subacute
back pain,71 and an exercise programme plus spinal manipulation from a chiropractor, osteopath or physiotherapist at a private or National
Health Service (NHS) site in the UK for low-back pain.68 The average percentage of applicable BMJ checklist items met by each study was slightly lower for those studies with at least one cost-saving comparison (85% vs 88%),
but the difference was not statistically significant (t test=0.75, p value=0.460).

Discussion

This comprehensive systematic review identified 338 economic evaluations of CIM; 204 of which were published recently (2001–2010)
covering a wide range of CIM therapies for a variety of populations. Although most patients who use CIM use more than one
modality35 and despite the attention given to integrative medicine (coordinated access to conventional medicine and CIM),105 this systematic review found only one study that examined the effects of use of multiple CIM practitioners.52 In general, the quality of the recent full economic evaluations has held constant and is in line with what is seen in economic
evaluations in conventional medicine. Details of the 31 recent higher-quality full economic evaluations indicate potential
cost-effectiveness and cost savings across a variety of CIM therapies applied to different conditions. Owing to the non-generalisable
nature of economic evaluations, the cost estimates shown are specific to their study settings.40 However, 22 articles provided at least the minimum information for study transferability. Therefore, their results could
be adapted via modelling to determine the economic impact of these interventions in other settings.

The strengths of this study are the comprehensive search strategy, which revealed a substantial number of published economic
evaluations of CIM, the use of two reviewers and the use of multiple measures of study quality. Higher-quality studies were
identified and highlighted for policy makers using a simple objective list of quality criteria, which reduced the potential
for bias. The weaknesses of this study are similar to those of the other systematic reviews. The reviewers were not blinded
to journals and article authors, which may have influenced results. Also, some aspects of what makes a quality economic evaluation
could not be judged from what was reported. For example, ideally, pragmatic trials enrol patients typical of normal caseload
in typical settings with typically trained and experienced practitioners following them under routine conditions (ref.37, p. 251). Judgements as to whether these criteria were met were not always possible from the reports, and were beyond the
scope of this review. Finally, publication bias was not assessed. However, since the major goal of this study was to establish
the extent of the published literature on this topic and to highlight the results of the higher-quality studies, it is not
clear that publication bias is relevant here.

The number of economic evaluations of CIM found and reviewed by this study far exceeds the numbers found in previous studies.11,19–21,23 This study found a total of 338 economic evaluations of CIM published between and including 1979 and 2010; 211 of these were
full economic evaluations. White and Ernst19 identified 34 economic evaluations of CAM published 1987–1999; 11 of which were full economic evaluations. Between 1999 and
October 2004, Herman et al20 identified 56 economic evaluations of CAM (39 full evaluations). Between 1994 and May 2004 Hulme and Long21 identified 19 full economic evaluations of CAM, and over a similar period (1995–2007) Doran et al23 found 43 economic evaluations (15 full evaluations). Maxion-Bergemann et al11 identified 5 (1 full) economic evaluations over an unspecified search period. The large number of economic evaluations found
in this study reflects the facts that: (1) all evaluations from previous reviews were included; (2) a number of studies have
been published since the last search dates of prior reviews and (3) a more extensive search strategy was used. It should be
noted that 20% of the articles (68 of 338) in this review were identified through bibliography searches and from expert lists.
Therefore, even the application of a long list of search terms to multiple databases does not guarantee that all CIM studies
will be identified. However, there is some evidence that the indexing of these articles in medical databases is improving;
studies from bibliographies and expert lists made up 32% of found articles published 2000 and before, but only 12% recent
articles.

There are several implications of this study for policy makers, clinicians and future researchers. First, there is a large
and growing literature of quality economic evaluations in CIM. However, although indexing is improving in databases, finding
these studies can require going beyond simple CIM-related search terms. Second, the results of the higher-quality studies
indicate a number of highly cost-effective, and even cost saving, CIM therapies. Almost 30% of the 56 cost-effectiveness,
cost-utility and cost-benefit comparisons shown in table 4 (18% of the CUA comparisons) were cost saving. Compare this to 9% of 1433 CUA comparisons found to be cost saving in a large
review of economic evaluations across all medicine.106 Third, by meeting the five study-quality criteria, the studies shown in table 4 can each be considered a reasonable indicator of the health and economic impacts of the CIM therapy studied, at least in
that population and setting. These studies, especially those showing cost savings, should be considered further for applicability
in other settings. This requires the study to be transferable.39 Fortunately, the majority of the higher-quality studies met our measure of study transferability—resource use or model parameters,
and unit costs were reported separately.

Given the substantial number of economic evaluations of CIM found in this comprehensive review, even though it can always
be said that more studies are needed, what is actually needed are better-quality studies—both in terms of better study quality
(to increase the validity of the results for its targeted population and setting) and better transferability (to increase
the usefulness of these results to other decision makers in other settings). Therefore, the following recommendations are
made.

That all studies measuring the effectiveness of CIM at least consider also measuring input costs and economic outcomes.

That at least one arm of the study be some version of commonly available (usual) care, and that usual care and all interventions
studied be described in sufficient detail that decision makers in other settings can determine what was done and whether the
study's usual care comparator is applicable in their setting.

That consideration be given to how CIM is typically used (eg, multiple CIM therapies) or can be used (eg, coordinated integrative
care models) when designing studies.

That changes in resource use be reported separately from unit costs in economic evaluations alongside clinical trials and
that model parameters and unit costs be clearly reported in decision-analytic modelling studies.

That all economic evaluations contain sensitivity analyses to increase the reliability of results.

That more consideration be given to modelling as a method to estimate economic outcomes for existing effectiveness trial results,
and to generalise existing quality economic evaluation results to other jurisdictions.

Acknowledgments

The authors wish to acknowledge and most gratefully thank Sandy Kramer of the University of Arizona Health Sciences Library
for her assistance in the development and application of the search strategy and for eliminating duplicates from the search
results. We would also like to thank Robert Scholten and P Scott Lapinski of the Harvard Medical School for their assistance
with the EMBASE searches.

Footnotes

Contributions PMH conceived of the idea for the paper, designed the search strategy, reviewed the references found, extracted the data
from each included article and is the guarantor for this study. In parallel, BLP also reviewed the references found, extracted
data from included articles and worked with PMH to resolve any discrepancies between reviewers. CMW provided practical insight
and an international perspective to the design of the paper and interpretation of results. DME participated in the early design
of the study, including the data extraction plan, inclusion/exclusion criteria and the interpretation of results. All authors
contributed to the drafting and editing of the manuscript.

Funding The Bernard Osher Foundation supports a portion of DME's time for research in integrative medicine. The Foundation had no
control or influence over the design or execution of this study, nor no input into this manuscript.

National Center for Complementary and Alternative Medicine. What is complementary and alternative medicine (CAM)? National Center for Complementary and Alternative Medicine. Bethesda, Maryland: National Institutes of Health, 2011.

Commonwealth Department of Health and Ageing. Guidelines for the pharmaceutical industry on preparaion of submissions to the pharmaceutical benefits advisory committee. Canberra: Commonwealth of Australia, 2002.

. The clinical effectiveness of glucosamine and chondroitin supplements in slowing or arresting progression of osteoarthritis
of the knee: a systematic review and economic evaluation. Health Technol Assess2009;13:1–148.

. Cost-effectiveness of breech version by acupuncture-type interventions on BL 67, including moxibustion, for women with a breech
foetus at 33 weeks gestation: a modelling approach. Complement Ther Med2010;18:67–77.